Method of optimizing healthcare services consumption

ABSTRACT

A method of optimizing healthcare services consumption according to the invention includes the steps of assessing the healthcare situation of an employer providing healthcare benefits to a population, identifying a first group of patients from the population likely to generate expensive healthcare claims based on data representing past claims, periodically determining whether patients in the first group have satisfied certain predetermined healthcare requirements, identifying a first group of providers who provide high quality, cost efficient healthcare services based on the practice patterns of the providers, prompting patients who have not satisfied the predetermined healthcare requirements to obtain services from providers in the first group, and responding to healthcare requests from patients by determining whether the requesting patient is seeking services from a provider in the first group, and, if not, urging the patient to obtain such services from a provider in the first group.

FIELD OF THE INVENTION

[0001] The present invention generally relates to a method of optimizinghealthcare services consumed by patients including employees and theirfamily members by improving the overall quality of care and reducing theoverall cost incurred by the employer, and more particularly to a methodfor application by a healthcare quality management firm (HOM) ofcharacterizing the healthcare situation of an employer who pays forhealthcare, comparing that healthcare situation to that of a geographicarea in which the employer resides, identifying factors affecting thequality and cost of the healthcare, and recommending action foraddressing the factors by applying resources at levels corresponding tothe relative affect of the factors on the quality and cost of thehealthcare.

BACKGROUND OF THE INVENTION

[0002] Employer sponsored healthcare benefits are of tremendous value toemployees and their families. Such benefits, on the other hand,typically constitute a significant portion of an employer's totaloperating costs. Unfortunately, as medical costs continue to increase,the cost of providing employer sponsored healthcare benefits willcontinue to increase.

[0003] Currently, many employers attempt to offset the rising costs ofproviding healthcare benefits by shifting the cost to employees. Ofcourse, only so much of the expense can be shifted to employees. At somepoint, the cost incurred by the employees will become prohibitive, andemployer sponsored healthcare will no longer be seen as a benefit. Someemployers attempt to monitor the price of certain healthcare services,but without information relating to the quality of the services, costinformation is of limited value. Other employers have attempted toreduce their healthcare expenses by sponsoring health fairs or wellnessscreenings. This approach, while somewhat effective in promptingpreventative healthcare, is not a focused expenditure of resources. Forthe majority of employees who are healthy, the money spent on wellnessscreenings is essentially wasted. Finally, employers sometimes attemptto negotiate the fixed costs associated with administering healthcarebenefits. Again, since these costs typically make up only a smallportion of the total cost, even successful negotiation attempts willhave a limited impact on the employer's bottom line.

[0004] In short, employers have been largely unsuccessful in theirattempts to control healthcare costs while ensuring a high level ofcare. Employers simply lack the information necessary to identify themost significant factors affecting their healthcare costs, to quantifyand compare the performance of healthcare providers, and to apply theirresources in a way that most effectively reduces both the overallconsumption of healthcare and the costs of the services consumed whilemaintaining or improving the quality of the healthcare benefits theyprovide.

SUMMARY OF THE INVENTION

[0005] The present invention provides a method of optimizing healthcareservices consumption through analysis of the demographic and wellnesscharacteristics of an employee population (including employees andemployee family members, hereinafter, “patients”), analysis of thequality and cost efficiency of the practices of providers used by thepatients, and intervention with patients and providers to improve theoverall health of the patients, the practices of the providers, and thecost efficiency of the employer provided healthcare plan. The method, inone embodiment thereof, includes the steps of assessing the healthcaresituation of the employer as it relates to normative characteristics ofa health economic zone including the patients, identifying patients fromthe covered population likely to generate expensive healthcare claimsrelative to the other patients based on data representing pasthealthcare claims generated by the patients, periodically determiningwhether these patients have obtained healthcare services that satisfypredetermined requirements, identifying qualified providers in thehealth economic zone who provide high quality, cost efficient healthcareservices relative to other providers in the health economic zone basedon data representing past practice patterns of the providers, promptingpatients who have not obtained healthcare services that satisfy thepredetermined requirements to obtain additional healthcare services fromthe qualified providers, and responding to healthcare requests frompatients by determining whether the requesting patient is seeking toobtain healthcare services from a qualified provider, and, if not,urging the patient to obtain services from a qualified provider.

[0006] The features and advantages of the present invention describedabove, as well as additional features and advantages, will be readilyapparent to those skilled in the art upon reference to the followingdescription and the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0007]FIG. 1 is a conceptual diagram of participants in a healthcareconsumption situation that may be optimized using a method according tothe present invention.

[0008]FIG. 2 is a conceptual diagram of an interrelationship between acentral database and the participants shown in FIG. 1.

[0009]FIG. 3 is a flow diagram depicting steps included in oneembodiment of the present invention.

[0010]FIG. 4 is a conceptual diagram of a health economic zone.

[0011] FIGS. 5-15 are illustrations of reports generated according to anembodiment of the present invention.

[0012]FIG. 16 is a flow diagram of a process for evaluating the practicecharacteristics of healthcare providers.

[0013]FIG. 17 is a flow diagram depicting steps included in oneembodiment of the present invention.

DETAILED DESCRIPTION OF EMBODIMENTS OF THE INVENTION

[0014] The embodiments described below are merely exemplary and are notintended to limit the invention to the precise forms disclosed. Instead,the embodiments were selected for description to enable one of ordinaryskill in the art to practice the invention.

[0015]FIG. 1 depicts a relationship among participants in a typicalemployer provided healthcare situation. In this example, the employer 10is self-insured and provides funds, based on predicted healthcare costs,to a third party administrator (TPA 12) of healthcare benefits forpaying employee healthcare claims. Of course, also involved in thisrelationship are the healthcare consumer, patient 14, the healthcareprovider 16 (e.g., a physician or a facility such as a hospital,laboratory, etc.), a pharmacy 18, a pharmacy benefit manager (PBM 19), aPPO 20, and a healthcare quality management firm (HQM 13). As shouldbecome apparent from the following description, HQM 13 could perform thefunctions of TPA 12. Thus, except where expressly indicated otherwise ormandated by the context of this description, references to HQM 13 mayinclude HQM 13 and TPA 12.

[0016] In a typical transaction associated with a healthcare claim,patient 14 visits provider 16 to obtain healthcare services and/orproducts such as drugs. For simplicity, this description collectivelyrefers to services and products as healthcare services. Provider 16submits a claim to PPO 20 (or alternatively directly to TPA 12) in anamount corresponding to the cost of the services. Provider 16 may alsowrite a prescription that is received by a pharmacy 18. In that event,pharmacy 18 submits a claim to PBM 19, which in turn submits a claim toTPA 12. As is well known in the art, PPO 20 (or alternatively TPA 12)typically discounts or reprices the claimed charges based on anagreement between provider 16, pharmacy 18, and PPO 20. The repricedclaim is submitted to TPA 12 for payment. TPA 12 accesses funds in thehealthcare account of employer 10 to pay provider 16 and PBM 19 therepriced claim amounts. PBM 19 then forwards a payment to pharmacy 18.TPA 12 then also informs patient 14 of the patient's paymentresponsibility that arises as a part of the application of the terms ofthe underlying benefit plan when it does not pay 100% of eligiblecharges. Patient 14 then sends a payment to provider 16. Theabove-described example assumes that TPA 12 is separate from HQM 13. IfHQM 13 functions as a combination of HQM 13 and TPA 12, then HQM 13interacts directly with employer 10, patient 14, provider 16, PBM 19,and PPO 20 in the manner described with reference to TPA 12 above.

[0017] As should be apparent from the foregoing, throughout each suchtransaction, TPA 12 has access to all of the material claim information.TPA 12 shares this information with HQM 13, which may contact employer10, patient 14, and/or provider 16. Accordingly, as will be described indetail below, HQM 13 is in a position to facilitate change in and/ordirectly influence the healthcare situation to control the cost incurredby employer 10 and to encourage consumption of healthcare from highquality providers 16. Thus, HQM 13 is described below as practicing thepresent invention as a service for the benefit of its clients, employers10, and patients 14 including the clients' employees and their familymembers.

[0018] According to one embodiment of the present invention, TPA 12maintains a database 22 including a variety of different types ofinformation from employer 10, provider 16, PBM 19, and PPO 20 asdepicted in FIG. 2. As is further described below, TPA 12 also updatesinformation included in database 22 as a result of its interaction withHQM 13. Database 22 may be maintained on any of a variety of suitablecomputer-readable media such as a hard drive of a computer. While FIG. 2suggests contributions of information to database 22 by each of employer10, TPA 12, provider 16, PBM 19, and PPO 20, it should be understoodthat such information may not be provided directly to database 22.Instead, TPA 12 may receive information from the other participants andenter and/or otherwise process the information for storage in database22. For example, information may be transferred electronically fromemployer 10, provider 16, PBM 19, PPO 20, and HQM 13 to TPA 12 via anetwork or multiple networks. Moreover, TPA 12 may physically reside atmultiple locations, each of which receives information from the otherparticipants. Such multiple locations may be connected together via anetwork configured to permit simultaneous access to database 22 througha server. Any suitable method of transferring information and storingsuch information in either a centralized or distributed database 22 iswithin the scope of the invention. For simplicity, the transfer ofinformation is described herein as occurring electronically over anetwork, and database 22 is described as a centralized databaseaccessible by a single TPA 12 location.

[0019] As is further described below, the information stored in database22 permits HQM 13 to evaluate the healthcare situation of employer 10,including the cost information, the healthcare characteristics ofpatients 14, and the performance of providers 16 used by patients 14covered under the healthcare plan provided by employer 10. Accordingly,the information in database 22 includes employer information, patientinformation, provider information, pharmacy information, and claimsinformation that may relate to some or all of the other types ofinformation. The employer information includes information identifyingemployer 10, patients 14 covered under the employer provided healthcareplan, PPO 20 associated with employer 10, as well as historical datathat characterizes changes in the healthcare situation of employer 10over time. The patient information includes the name, address, socialsecurity number, age, and sex of each patient 14 covered under thehealthcare plan provided by employer 10. The provider informationincludes the name, tax identification number, address, and specialty ofa plurality of healthcare providers across a large geographic region,such as the entire United States. As is further described below,portions of the provider information are associated with employer 10.These portions correspond to the providers 16 that provide services topatients 14. The pharmacy data includes information identifying thetype, quantity, and dosage of drugs associated with a particularprescription for a particular patient 14 as well as the social securitynumber of the patient 14. This information permits association ofprescription drug claims with patients 14. These claims can be furtherassociated with the provider 16 that wrote the prescription by accessingthe claims data (described below) associated with the patient 14 whofilled the prescription to determine which provider 16 patient 14 sawprior to obtaining the prescription. Alternatively, an identifier may beincluded in the pharmacy data with each prescription entry thatidentifies provider 16.

[0020] The claims data stored in database 22 include portions of theabove-described data, but may be organized or associated with aparticular claim. More specifically, a claim may include informationidentifying and/or describing employer 10, patient 14, provider 16,pharmacy 18, PBM 19, and PPO 20. The claim may further includeinformation describing the condition or symptoms of patient 14 thatgenerated the claim, the diagnosis of provider 16, the proceduresordered by provider 16 to treat the diagnosed condition as identified bycommonly used procedure codes, and the costs (both original charges andrepriced amounts) of the healthcare services associated with the claim.

[0021] As indicated above, the information stored in database 22 comesfrom a variety of sources. For example, when an employer 10 becomes anew client of HQM 13, PPO 20 servicing employer 10 may provide HQM 13with enrollment data including employer information, employeeinformation, and associated past claims information. HOM 13 may thenprocess that information for addition to database 22. Periodically, PPOs20 of employers 10 transfer claims information to TPA 12 (i.e., as theclaims information is processed by PPOs 20). As indicated above, inaddition to information relating to associated healthcare services, thisclaims information may include employee information, providerinformation, and pharmacy information. Additionally, PBMs 19 (or datatransfer services working with PBMs 19) periodically transfer pharmacyinformation to TPA 12. As further described below, each time newinformation is provided to TPA 12, TPA 12 and/or HOM 13 may process theinformation such that it is associated with a particular employer 10, aparticular patient 14, or a particular provider 16.

[0022] Referring now to FIGS. 3 and 4, one embodiment of the methodaccording to the present invention may be generally described asinvolving three basic steps: analyzing the healthcare situation ofemployer 10, improving the healthcare consumption characteristics ofpatients 14, and improving the overall performance characteristics ofproviders 16 used by patients 14. One process for analyzing a healthcaresituation of an employer 10 is depicted in FIG. 3. In general, after allof the relevant information regarding employer 10, patients 14associated with employer 10, and providers 16 used by patients 14resides in database 22, HQM 13 executes software (as further describedbelow) to access database 22 and identify a Healthcare Economic Zone(HEZ 24, FIG. 4) corresponding to employer 10 (step 26). As shown inFIG. 4, HEZ 24 corresponds to a geographic area that includes allpatients 14 associated with all employers 10 and providers 16 used bypatients 14 (including physicians 28 and facilities 30, such ashospitals). HEZ 24 may be defined to correspond to Hospital ServiceAreas set forth by the Dartmouth Atlas project, a funded research effortof the faculty of the Center for the Evaluative Clinical Sciences atDartmouth Medical School. Essentially, HEZs are based on the zip codesof the residential addresses of patients 14 stored in database 22 andthe locations of providers 16 servicing those zip codes. In other words,an HEZ 24 includes a geographic region in which patients 14 tend toobtain their primary healthcare. For example, assuming patients 14associated with employer 10 all reside in three adjacent zip codes thatare serviced by one facility 30 (also within one of the three zipcodes), then those three zip codes are included in HEZ 24. However, iffacility 30 also refers patients 14 to, for example, specialistproviders 16 in a fourth zip code, then the fourth zip code is alsoincluded in HEZ 24. FIG. 4 shows HEZ 24 fully contained within a largergeographic area such as a state 32. It should be understood, however,that HEZs 24 (or the equivalent of HEZs 24) may extend across statelines.

[0023] Referring again to FIG. 3, step 34 indicates that information indatabase 22 corresponding to employer 10 (i.e., employer information,patient information, claims information corresponding to patients 14associated with employer 10, and provider information) is analyzed toevaluate the healthcare situation of employer 10. In step 36, theemployer specific data is compared to generalized data relating to HEZ24 as is further described below. As indicated in FIG. 3, the results ofthe analyses performed in steps 26, 34, and 36 may be processed in theform of provider reports 38, employer reports 40, and patient reports42, some or all of which may be provided to employer 10 as shown in FIG.1 as part of the process of analyzing the healthcare situation ofemployer 10. Step 44 depicts the process of updating database 22 as HOM13 and/or TPA 12 receive claims information and/or changes in thepopulation of patients 14 associated with employer 10 as a result ofemployees being hired by or departing from employer 10, or changes inthe family situation of the employees. As should be apparent from thefigure, the process of analyzing the healthcare situation of employer 10is therefore continuously updated and may result in generation ofperiodic reports for employer 10 and HQM 13 to track changes in thehealthcare situation over time.

[0024]FIG. 5 depicts an example of an employer report 40. Although chart46 of FIG. 5 does not compare employer 10 information to HEZ 24information, it is an employer report 40 because it provides employer 10information regarding the costs of healthcare services in the HEZ 24 inwhich employer 10 (more accurately, patients 14 associated with employer10) resides. Chart 46 includes a specialty column 48, a total allowedcharges column 50, a total allowed charges at normative costs column 52,a percent of excess charges column 54, and an excess charge per life peryear column 56. Chart 46 provides employer 10 information regarding therelative costs of healthcare services (by specialty) in the employer'sHEZ 24 as compared to the costs in a larger geographic area thatincludes HEZ 24 (e.g., state 32, the Midwest, the southeast, etc.). Inthis example, providers 16 in HEZ 24 charged $4,251,526 (column 50) forcardiology services over the course of a predetermined time period, suchas two years. Column 52 shows that the normative costs for such servicesis $4,488,559 for the same number of healthcare consumers (i.e.,patients 14) over the same predetermined time period. More specifically,the dollar amounts in column 52 are derived by first adding all of thecharges for cardiology services in the larger geographic area for thepredetermined time period and dividing the total by the number ofhealthcare consumers in the larger geographic area. Then, this “averagecardiology charge per healthcare consumer” is multiplied by the numberof healthcare consumers in HEZ 24. As shown in column 54, HEZ 24experienced cardiology costs that were 5.3 percent below the normativecardiology charges. Finally, column 56 simply converts the percentagedeviation from the normative charge into a dollar value divided by thenumber of healthcare consumers in HEZ 24 and the number of years in thepredetermined time period.

[0025] Line 58 shows the totals for all specialties or Major PracticeCategories (MPCs). Lines 60 and 62 illustrate a situation wherein HEZ 24is serviced by more than one PPO 20. Since all of the claims informationin database 22 is associated with a particular PPO 20, the chargesassociated with all claims of healthcare consumers in HEZ 24corresponding to PPO network A and PPO network B may be separated basedon the PPO that handled the claim. Thus, lines 60 and 62 depict therelative usage of the PPOs by healthcare consumers in HEZ 24 (column50), the normative usage values for each PPO in a larger geographic area(e.g., state 32) (column 52), the cost performance of the PPOs for HEZ24 relative to the cost performance of the PPOs across state 32 (column54), and the meaning of that relative performance on a dollars perpatient 14 per year basis (column 56). Lines 64 and 66 provide similarinformation for two hospitals used by healthcare consumers in HEZ 24.

[0026] As should be apparent from the foregoing, employer 10 may readilyscan down total allowed charges column 50 to determine the specialtiesmost likely to contribute significantly to the employer's overallhealthcare costs. Columns 54 and 56 permit employer 10 to readilyidentify those practice categories having charges that deviate most fromthe average or normative charges. In this manner, employer 10 (and HOM13) can isolate the practice categories that have the most potential forproviding the most significant reduction in the overall healthcare costsof employer 10.

[0027] Another employer report 40 (chart 68 of FIG. 6) follows the sameformat as chart 46, but compares the actual healthcare costs of employer10 to the typical costs in HEZ 24. Chart 68 includes a specialty column70, a total costs column 72, a normalized costs in HEZ 24 column 74, apercent excess column 76, and an excess cost per life per year column78. Column 72 represents the total costs employer 10 incurred for thevarious specialties listed in column 70 during a predetermined timeperiod. The normalized amounts in column 74 represent the expected costin HEZ 24 for an employer having the same number of patients 14 as areassociated with employer 10. For example, assuming a total cost forcardiology in HEZ 24 of $17,122,789 for 35,623 healthcare consumers inHEZ 24, the average cardiology cost per healthcare consumer is $480.67.Assuming that employer 10 has 150 patients 14, then the expected totalcost for cardiology services (i.e., the normalized costs in HEZ 24,column 74) is $72,100. Accordingly, employer 10 has incurred costs forcardiology services that are 23.7% below the anticipated amount for anemployer the size of employer 10 located in HEZ 24 as shown by column76. Column 78 reflects this percentage in a per patient 14 per yeardollar value.

[0028] As should be apparent from the foregoing, chart 68 could readilybe revised to reflect similar information for actual consumers of theparticular specialties as opposed to patients 14 and healthcareconsumers generally. In other words, if only nine patients 14 usedcardiology services over the predetermined time period (resulting in atotal cost of $55,000), column 74 could be modified to reflect theexpected amount for nine of the average consumers of cardiology servicesin HEZ 24 over the predetermined time period. Of course, columns 76 and78 would then reflect the difference between these values on apercentage and per life per year basis, respectively.

[0029]FIG. 7 is another employer report 40 that summarizes the illnessburden and demographics of HEZ 24 associated with employer 10. Chart 80includes a description column 82, an HEZ 24 data column 84, a normativevalue a larger geographic area including column 86 for HEZ 24, a percentexcess column 88, and an excess per life per year column 90. It is wellknown that healthcare consumption is greater for adults verses children(other than newborn children), for females verses males, and for olderadults verses younger adults. Obviously, healthcare consumption is alsogreater for individuals having certain types of pre-existing illnessesas compared to healthy individuals. The method of the present inventionuses these factors to compute a healthcare index (line 92 in FIG. 7) forHEZ 24 in which patients 14 associated with employer 10 reside. Themethod of the present invention calculates the healthcare index for anHEZ 24 using Episode Risk Group (ERG) scores inherent in the health riskassessment process provided by Symmetry Health Data Systems, Inc. anddescribed in “A New Approach to Health Risk Assessment,” a white paperavailable from Symmetry Health Data Systems, Inc., the disclosure ofwhich is hereby incorporated herein by reference. A healthcare index foreach patient 14 in HEZ 24 is computed using a retrospective analysis,and the index for HEZ 24 is derived by calculating an average index forall patients 14 in HEZ 24. As shown in column 84 of FIG. 7, HEZ 24 has9,808 patients 14 having an average age of 42, and comprising 74.8%adults, 38.6% of whom are female. These factors result in a healthcareindex for HEZ 24 of 1.506. As shown in column 88, this healthcare indexis 50.6% above the normative healthcare index of 1.0 for the largergeographic area. This high healthcare index results from a higher thantypical percentage of females and adults in HEZ 24 and a higher thantypical percentage of individuals with health risk factors. Morespecifically, as shown in column 88 of FIG. 7, 10.8% of the overage isdue to atypical demographics (i.e., an older and more heavily femalepopulation). 39.8% of the overage is due to the atypical illness burdenof the population (i.e., a population with health conditionscorresponding to higher than typical health risk factors). Accordingly,an employer 10 in HEZ 24 should expect to have healthcare costs that aregreater than the typical costs of the larger geographic region. Itshould be understood that a similar report could readily be generatedcomparing the illness burden and demographic information of a particularemployer 10 to information describing the HEZ 24 in which patients 14associated with employer 10 reside.

[0030] Referring now to FIG. 8, a patient report 42 is shown summarizingthe chronic illnesses of patients 14 associated with employer 10. It iswell known that typically 80% of an employer's healthcare costs aregenerated by approximately 20% of the covered population of patients 14.That 20% of the population generally has a high incidence of chronicillness. Accordingly, chart 94 of FIG. 8 is generated to provideemployer 10 a summary of its chronically ill patients 14.

[0031] As shown, column 96 lists various chronic illnesses. While themethod of the present invention may track any number of chronicillnesses, only six are shown in FIG. 8. Column 98 shows the number ofpatients 14 having each of the listed illnesses. Column 100 shows thenumber of those patients 14 listed in column 98 that have at least oneyear of claims history (i.e., have submitted claims that were added todatabase 22). Column 102 shows the number of patients 14 that havesatisfied the minimum annual care requirements (MACRs) recommended fortreating the chronic illness or illnesses from which they suffer. Column104 simply expresses the number in column 102 in the form of apercentage of the total patients 14 suffering from the listed illness.The MACRs for each chronic illness of chart 94 are listed in column 106and obtained using software available from McKesson Corp., a supplier ofinformation and managed care products and services for the health careindustry. In particular, McKesson's CareEnhance Resource ManagementSoftware (CRMS) provides such information. As the method of optimizinghealthcare services consumption described below is practiced, periodicreports such as chart 94 of FIG. 8 will show improvements in the numberof patients 14 that satisfy the MACRs associated with their particularillness(es).

[0032] Chart 110 of FIG. 9 shows the chronic illness status of patients14 associated with employer 10 in terms of co-morbidities. Chart 110includes a description column 112, a current patient column 114, apercent of current covered patients column 116, a previous patientcolumn 118, a percent of previous covered patients column 120, and apercent of database driven norms column 122. As shown in column 114, ofthe 993 total patients 14 covered under a healthcare plan provided byemployer 10, a total of 619 have a single chronic illness, 236 have twochronic illnesses, 86 have three chronic illnesses, etc. Column 116expresses the number of patients 14 listed in column 114 in terms of thepercentage of the total patient 14 population. Columns 118 and 120include similar information representing the status of the chronicallyill at a previous date. Employer 10 can monitor changes in the chronicillness status of its patients 14 by comparing these two sets ofcolumns. Finally, column 122 shows the typical percentage of individuals(based on all individuals reflected in the database) with the particularnumber of chronic illnesses.

[0033] In addition to summarizing patients 14 having chronic illnesses,the method of the present invention also includes the step of performinga risk stratification of all patients 14 covered by employer 10. Theresults of this risk stratification step are provided to employer 10 asan patient report 40. Chart 124 of FIG. 10 is an example of such anpatient report 42. As shown, chart 124 includes a family identificationnumber column 126, a patient identification column 128, an age column130, a gender column 132, a healthcare index column 134, and a predictedcost column 136. The primary purpose of chart 124 is to display patients14 in order of their associated healthcare index listed in column 134.The healthcare index is derived using the McKesson CRMS software asdescribed above, which takes into account the age, gender, chronicillnesses, and co-morbidities of each patient 14. Also, by analyzingclaims data describing prescriptions, the CRMS software imputesillnesses of patients 14 based on the number and types of medicationsprescribed for patients 14. Thus, the healthcare index is used to rankpatients 14 in terms of their likelihood of generating large medicalexpenses in the near future. It should be noted that not only thechronically ill are identified by the healthcare index. Other patients14 having conditions that are not considered chronic may have highhealthcare indices. Column 136 provides a predicted cost associated witheach patient 14 based on their healthcare index. More specifically,column 136 is derived by calculating the total expense associated withthe normative population, and dividing that amount by the total numberof ERG risk points of the normative population to get dollars per riskpoint (prospectively). Then, using the method of the present invention(and not the CRMS software), the healthcare index of column 134 ismultiplied by the dollars per risk point value.

[0034] The above-described employer reports 40 and patient reports 42are illustrative of the way in which the method of the present inventiondetermines which patients 14 covered by employer 10 should receiveintervention or proactive coaching (as further described below anddepicted in FIG. 1), and at what level of intensity. In other words,since chronically ill patients 14 generally generate large healthcarecosts, chronically ill patients 14 should be monitored and coached mostactively and at levels corresponding to the number of chronic illnessesfrom which they suffer. Likewise, patients 14 having high healthcareindices because of their age, gender, illnesses, etc. should bemonitored and coached most actively and at levels corresponding to theirhealthcare index. Using the above-described approach, patients 14 thatrequire proactive coaching typically constitute approximately 25% of thetotal patient 14 population. It has been shown that this 25% portion ofthe patient 14 population typically generates 90% of the totalhealthcare costs incurred by employers 10.

[0035] As indicated above, the method of the present invention alsogenerates physician reports 38 such as chart 138 shown in FIG. 11. Chart138 is an example of a comparison of various characteristics of thepractice of a particular provider 16 to the practices of other providers16 in the same specialty. In order to make such comparisons, the claimsinformation in database 22 may be analyzed on the basis of “episodes” ofhealthcare. This analysis is performed using software applicationsavailable from McKesson Corp., which analyze the services and costsassociated with claims originated by a particular provider 16. Anepisode is defined as a healthcare consumption sequence including allhealthcare services consumed by a patient 14 for a particular healthcareproblem. Episodes may include healthcare services ordered by a physicianas a result of an initial office visit (e.g., tests, X-rays, etc.),healthcare services associated with a subsequent hospital visit (e.g.,for surgery), and healthcare services associated with aftercare orfollow-up visits to the physician.

[0036] The analysis of claims information grouped by specialty episodespermits identification of providers 16 having practice patterns thatresult in low total costs for the types of healthcare problems theytreat as compared to other providers 16 in the specialty. Additionally,providers 16 who deliver high levels of post-primary preventative careservices for chronically ill patients 14 can be identified. Finally,specific undesirable characteristics of a provider's 16 practicepatterns can be identified such as up-coding, ordering inappropriateservices, vague or invalid diagnostic codes, and services that areperformed too frequently. All of this information is available from theclaims information stored in database 22.

[0037] Referring back to FIG. 11, Bar 140 of chart 138 represents thepercentage of procedures ordered by a particular provider 16 (physicianID #223776) that were determined to be inappropriate for the diagnosisreflected in the claims information associated with the evaluatedepisodes. Bar 142 represents similar data for the entire specialty.Comparing bar 140 to bar 142 shows that this particular anesthesiologistordered inappropriate procedures at nearly double the rate of others inthe specialty. The remaining bar groups 144, 146, 148, 150, and 152permit similar comparisons for the practice pattern characteristicsindicated on chart 138.

[0038] As further described below, one of the steps of a methodaccording to the present invention involves determining whetherproviders 16 used by employees 14 of employer 10 provide healthcare in amanner that satisfies certain criteria. If so, these providers 16 areidentified as Quality Service Providers or QSPS. To achieve a QSPdesignation or rating, providers 16 must, based on claims informationstored in database 22, pass three screens or quantitative tests of theproviders' 16 performance or practice characteristics. Any provider 16who fails one or more of these tests is identified for purposes ofpracticing the present invention as a non-certified QSP (“NCQSP”).

[0039] The first test (“the CEI test”) is primarily economic. Usingclaims information in database 22, the software of the present inventiongenerates a Cost Efficiency Index (CEI) for each provider 16. The CEIrepresents the actual total cost of care provided and/or ordered byprovider 16 for completed episodes, divided by the total average cost ofsuch care for similar episodes treated by other providers 16 in thespecialty. In other words, the cost to employer 10 for the healthcaredelivered and/or ordered by provider 16 for all completed episodes forall patients 14 is first extracted from the claims information indatabase 22. Then, the total cost for all similar episodes handled byall providers 16 tracked in database 22 is determined, and divided bythe total number of episodes to arrive at an average cost per episode inthe specialty. Finally, the average cost per episode for provider 16 isdivided by the average cost per episode in the specialty to arrive atthe CEI for provider 16. If provider 16 has a CEI that exceeds apredetermined threshold (e.g., 125% or more above that of others in thespecialty of provider 16) and is statistically higher that the averagefor the specialty (i.e., sufficient claims information is contained indatabase 22 to calculate the CEI of provider 16 with a statisticallyacceptable confidence level such as at the p 0.1 level), then provider16 failed the CEI test and will be designated a NCQSP. A sample reportof the data used to complete a CEI analysis is shown in FIG. 12.

[0040] The second test in the QSP rating process (“the service ratetest”) evaluates the preventative care practices of providers 16. As iswell known in the field of medical care, preventative care services maysignificantly affect the overall cost of healthcare, particularly thoseservices provided to treat chronic illnesses to prevent those illnessesfrom progressing or resulting in other health complications. TheMcKesson software permits extraction of data representing the number andtypes of preventative care services ordered by providers 16 fortreatment of chronic conditions. In one embodiment of the invention,nineteen chronic conditions are tracked. To evaluate a particularprovider 16, the data representing the preventative care services forprovider 16 is extracted and compared (according to the method of thepresent invention) to a minimum number and particular types of servicesconsidered acceptable in treatment of the particular chronic conditionstreated by provider 16. This analysis results in a service rate forprovider 16. More specifically, the total number of services ordered forchronically ill patients treated by provider 16 is determined, and thendivided by the number of services required for such patients to achievecompliance with the associated MACRs. This service rate, or fraction ofrecommended MACRs, is then compared to the typical service rate in theappropriate specialty. If provider 16 has a service rate that is bothless than a certain percentage of the typical service rate (e.g., hasordered 75% or less of the services required to achieve compliance withthe associated MACRs) and statistically significantly lower than theaverage for the specialty (i.e., a statistically significant sample sizeis available in database 22 to obtain confidence at the p 0.1 level),then provider 16 failed the service rate test and is designated a NCQSP.A sample report representing the results of a service rate analysis isshown in FIG. 13.

[0041] The third test (the “practice patterns test”) involves anevaluation of the overall practice patterns of providers 16. Morespecifically, the McKesson clinical software is used to extract thenumber of occurrences of up-coding, ordering inappropriate services,vague or invalid diagnostic codes, and services that are performed toofrequently, both for the particular provider 16 being evaluated, and forthe specialty as a whole. Each practice pattern category is evaluatedaccording to the method of the present invention to determine whetherprovider 16 practices in a manner that results in a practice patternschallenge rate that exceeds a predetermined multiple of the typicalpractice pattern percentages (e.g., 200% or more than the typicalpractice patterns) and is statistically significantly higher than theaverage percentages (e.g., at the p 0.01 level). If so, provider 16failed the practice patterns test and is designated a NCQSP. A samplereport representing the results of a practice patterns analysis is shownin FIG. 14.

[0042] According to the present invention, providers 16 that pass eachof the three tests are assigned a QSP designation, indicating thatproviders 16 practice high quality medicine in a cost effective manner.As will be further described below, these QSP providers 16 are targetedby the present method for providing a maximum percentage of the overallhealthcare consumed by patients 14 of employer 10. In addition to thebasic QSP/NCQSP distinction resulting from the above-described process,providers 16 may be further ranked based on the results of theabove-described tests. For example, the QSP category of providers 16 maybe divided into “A” level QSP providers 16 and “B” level QSP providers16. “A” level QSP providers 16 may be defined as providers 16 who havehistorical claims data in database 22 representing at least fiveepisodes of the relevant type (“sufficient episodic data”), pass the CEItest with a CEI of less than 100% of the typical CEI in the specialty,and pass both the service rate test and the practice patterns test. “B”level QSP providers 16 may include providers 16 who (1) do not havesufficient episodic data, or (2) have sufficient episodic data and passall three tests, but with a CEI of greater than or equal to 100% of thetypical CEI in the specialty.

[0043] Similarly, providers 16 falling into the NCQSP category may befurther ranked relative to one another to provide an ordered listing ofNCQSPs. For example, “C” level NCQSP providers 16 may be defined asproviders 16 who have sufficient episodic data, pass the CEI test, butfail one of the service rate or practice patterns tests (not both). “D”level NCQSP providers 16 may be defined as providers 16 who havesufficient episodic data and (1) fail the CEI test with a CEI of lessthan 150% of the typical CEI in the specialty or (2) fail both theservice rate and practice patterns tests. Finally, an “E” level NCQSPprovider 16 may be defined as a provider 16 with sufficient episodicdata who fails the CEI test with a CEI that is at least 150% greaterthan the typical CEl in the specialty. Thus, providers 16 may becategorized in levels “A” through “E.” This ranking permits targetingnot only QSPs, but “A” level and “B” level QSPs, or NCQSPs that at leasthave the best relative rankings on the list of NCQSPs.

[0044] Another example provider report 38 is shown in FIG. 15. Chart 154of FIG. 15 is a listing of NCQSPs in descending order. The group ofcolumns collectively assigned reference designation 156 identifies theproviders 16 by ID, name, and location. Column 158 lists the number ofepisodes in database 22 associated with each provider 16. Column 160lists the above-described CEI for each listed provider 16. The greaterthe CEI listed in column 160, the more significant the provider'sdeviation from the practice patterns of other providers 16 in thespecialty. Consequently, those providers 16 listed near the top of chart154 will provide healthcare resulting in a greater cost to employer 10.In one embodiment of the invention, listings of NCQSPs such as chart 154are divided into thirds for purposes of practicing the invention asfurther described below.

[0045] Referring now to FIG. 16, a flow diagram of the above-describedprocess for assigning QSP or NCQSP designations to providers 16 isshown. At step 162, claims information corresponding to a particularprovider 16 is extracted from database 22 to determine whether provider16 has sufficient episodic data (e.g., at least five episodes of therelevant type). If not, then provider 16 is designated an unknown, “B”level QSP. If provider 16 has sufficient episodic data stored indatabase 22, then each of the three above-described tests are performedas indicated at step 163. At step 164, the results of the CEI test areanalyzed. If the CEI is 125% or more greater than the typical CEI in thespecialty and satisfies the above-described statistical significancecriteria, then provider 16 is marked as failing the CEI test (step 165).Otherwise, provider 16 is marked as passing the CEI test (step 166).Similarly, the results of the practice patterns test are analyzed atstep 167. If provider 16 has a service challenge rate of 200% or morethan the typical rate in the specialty and satisfies the above-describedstatistical significance criteria, then provider 16 is marked as failingthe practice patterns test (step 168). Otherwise, provider 16 is markedas passing the practice patterns test (step 169). Finally, the resultsof the service rate test are analyzed in a similar manner at step 170,and provider 16 is marked as failing (step 171) or passing (step 172)the service rate test as a result of the analysis.

[0046] As shown at step 173, “A” level QSPs are identified as providers16 who are marked as passing all three tests and achieved a CEI of lessthan 1. If a provider 16 is marked as passing all three tests, but has aCEI that is greater than or equal to 1, then provider 16 is designated a“B” level QSP as indicated by step 174. The remaining providers 16 areNCQSP providers 16. At step 175, the method of the present inventionidentifies “C” level NCOSPs at step 176 as providers 16 who are markedas passing the CEI test, but failing one of the other two tests (but notboth). At step 177, the lowest level providers 16 (“E” level NCQSPs) areidentified as providers 16 who are marked as failing the CEI test with aCEI of at least 1.5. Any remaining providers 16 are designated “D” levelNCQSPs as indicated at step 161. “D” level NCQSPs include providers 16who are marked as failing the CEI test, but with a CEI of less than 1.5,and providers 16 who are marked as failing both the service rate andpractice patterns tests. This process of evaluating providers 16 forpurposes of determining QSP/NCQSP status and levels within each categoryis repeated periodically to maintain an updated listing in database 22.It should be further understood that the particular numeric thresholdvalues used in each of the three tests may readily be changed to affectthe number of providers 16 falling into each of the five levels withoutdeparting from the principles of the invention. The designations forproviders 16 resulting from the above-described process are used toimprove the quality and cost-efficiency of the healthcare servicesconsumed by employees 14 of employer 10 in the manner described below.

[0047] Referring now to FIG. 17, a flow diagram representing a portionof a method for optimizing healthcare services consumption is provided.At step 178, the claims information corresponding to patients 14 isextracted from database 22. Step 178 results in the data necessary toidentify patients 14 having chronic illnesses (step 180) and to rankpatients 14 according to the above-described risk stratification process(step 182). As indicated above and shown in FIG. 1, the method of thepresent invention, in one form thereof, involves intervention withpatients 14 by registered nurses and other staff of HQM 13. Thisintervention or proactive coaching follows one or both of the two pathsdepicted in FIG. 17. First, for patients 14 identified as having one ormore chronic illness, the method of the invention determines at step184, based on claims information associated with such patients 14,whether the MACRs associated with the illness(es) have been satisfied.If the MACRs for a particular patient 14 have not been satisfied, then arepresentative of HQM 13 (e.g., a registered nurse or other staffmember) contacts patient 14 to remind patient 14 of the need to schedulethe healthcare necessary to satisfy the MACRs. This contact may beaccomplished by any mode of communication including by phone, email,fax, mail, or any combination thereof. Preferably, the representative ofHQM 13 has a live conversation with patient 14 to impress upon patient14 the importance of satisfying the MACRs associated with the patient'schronic illness.

[0048] At step 188, the representative of HQM 13 may also contactprovider 16 of healthcare services associated with the chronicillness(es) of patient 14. As a result of this contact, therepresentative enlists the cooperation of provider 16 in the effort topersuade patient 14 to satisfy the MACRs. As should be apparent from theforegoing, a goal of this intervention is to improve the health ofpatient 14 and minimize the cost to employer 10 by avoiding theincreased healthcare expenses typically accompanying untreated chronicillnesses.

[0049] Steps 186 and 188 may result in the generation of a healthcarerequest. Specifically, patient 14 may respond to contact by therepresentative of HQM 13 by scheduling an evaluation by provider 16 orother action toward satisfying the MACRs associated with the chronicillness(es) of employee 14. Step 190 represents the possibility that ahealthcare request is generated. If so, the healthcare request isprocessed as described below with reference to the second path depictedin FIG. 17. Otherwise, a predetermined time period is allowed to passbefore repeating the process of checking the compliance of patient 14with the MACRs associated with the chronic illness(es) of patient 14 andcontacting patient 14 and provider 16. Step 192 indicates this delayperiod.

[0050] When healthcare requests are generated, either as a result of thefirst path of FIG. 17 described above, or simply during the ordinarycourse of employee healthcare consumption, HQM 13 receives thehealthcare request at step 194. The healthcare request is associatedwith a particular patient 14 based on the risk stratification processrepresented by step 182. By determining the risk ranking of therequesting patient 14, HQM 13 can perform intervention actions (asdescribed herein) in the order of ranking of patients 14. In otherwords, since it is not possible to contact every patient 14 submitting ahealthcare request, the ranking of patients 14 permits HQM 13 to focusfirst on patients 14 having a highest risk ranking, and then (time andresources permitting) patients 14 have a smaller likelihood ofgenerating high cost healthcare claims. The method of the presentinvention next accesses database 22 to determine whether provider 16associated with the healthcare request is currently designated a QSPaccording to the process described above. If patient 14 is requesting toobtain healthcare services from a QSP, then the healthcare request maybe processed according to conventional procedures without interventionby representatives of HQM 13 as indicated by step 196. Alternatively,the QSPs resulting from the above-described evaluation process may beranked relative to one another and categorized into, for example, the“A” and “B” level QSP classifications described above. In such analternative embodiment, an additional step (not shown) between step 196and step 194 of contacting an patient 14 requesting healthcare from a“B” level QSP may be provided. At that step, a representative of HQM 13may attempt to influence patient 14 to obtain such services from a “A”level QSP.

[0051] If, on the other hand, the healthcare request seeks services froma NCQSP, then the ranking of the NCQSP (derived as explained above withreference to FIG. 16) is determined at step 198. At step 200, arepresentative of HQM 13 contacts patient 14 who generated thehealthcare request to urge patient 14 to obtain the requested servicesfrom a QSP. The representative may explain to patient 14 that variousother providers 16 within geographic proximity to patient 14 (determinedin the manner described below) have achieved the OSP designation forhigh quality, cost efficient healthcare, while provider 16 selected bypatient 14 has not achieved that designation. The representative mayfurther explain the implications of obtaining healthcare services fromNCQSPs, and attempt to assist patient 14 in rescheduling the requestedhealthcare services with a QSP. Additionally, if patient 14 refuses toswitch to a QSP, the representative may attempt to persuade patient 14to at least switch to a NCQSP that is ranked at a higher level than thecurrently selected NCQSP.

[0052] As described above, at step 200 of FIG. 14, the representative ofHQM 13 may list for patient 14 the variety of other providers 16(specifically, QSPs) within a specific geographic proximity to patient14. Such a list is generated by accessing database 22 using a softwareinterface configured to permit the HQM 13 representative to input adesired radius extending from the location of patient 14, therebydefining an area of geographic proximity surrounding patient 14. Thesoftware accesses database 22, identifies the QSPs located within theselected geographic area, and provides a listing to the HOM 13representative. Using this software and method, the representative mayaccess listings of QSPs within, for example, a five mile, ten mile,and/or fifteen mile radius of patient 14.

[0053] In the event patient 14 refuses to obtain healthcare servicesfrom a provider 16 other than the currently selected NCQSP, the methodof the present invention determines (at step 202) the level ofintervention required to minimize the costs of such services whilemaintaining high quality healthcare and the specific actions associatedwith that intervention level. A plurality of actions may be taken by therepresentative of TPA 12, depending upon the level of interventionrequired. As described above, the NCQSP listings generated by thepresent invention may, for example, be divided into thirds (“C,” “D,”and “E” level NCQSPs). “E” level NCQSPs require the greatest level ofintervention because the healthcare provided by such NCQSPs, asevaluated by the three QSP tests described herein, most significantlydeviates from characteristics associated with desirable healthcareservices. “D” level NCQSPs require less intervention. Finally, providers16 designated “C” level NCQSPs require the least intervention. This“stepped-down” approach to intervention permits efficient usage of theresources available to HQM 13 in managing the healthcare expenses ofemployer 10.

[0054] As indicated above, providers 16 at the top third of a NCQSPlisting (“E” level NCQSPs) receive the highest level of monitoring andindividual contact by representatives of HQM 13. If an “E” level NCQSPis identified at step 198 of FIG. 17, then step 202 obtains a listing ofintervention actions associated with “E” level NCQSPs. These actions mayinclude the following:

[0055] (1) Obtain criteria for any admission associated with thehealthcare request, including medical history, tests, and lab work;

[0056] (2) Delay any admission for employee 14 until all days ofadmission are approved by an appropriate representative of HQM 13;

[0057] (3) Complete a telephone evaluation with the NCQSP provider 16,conducted by an appropriate HQM 13 representative, to evaluate anddiscuss the need for any admission;

[0058] (4) Review the need to continue an admission after each day ofthe admission;

[0059] (5) Delay any additional days of admission beyond the initiallength of stay until such additional days are approved by an appropriaterepresentative of HQM 13;

[0060] (6) Assign a representative of HQM 13 to provide assistance toprovider 16 in determining appropriate services to address thehealthcare problem and to report treatments proposed by provider 16 toan appropriate representative of HOM 13; and

[0061] (7) Contact provider 16 directly to discuss any questionableproposed treatments as determined by an appropriate representative ofHQM 13.

[0062] If a “D” level NCQSP is identified at step 198 of FIG. 17, thenstep 202 obtains a listing of intervention actions associated with “D”level intervention. These actions may include the following:

[0063] (1) Obtain criteria for any admission associated with thehealthcare request, including medical history, tests, and lab work;

[0064] (2) Assign a one-day length of stay and perform daily concurrentreview of additional days, requiring approval by an appropriaterepresentative of HQM 13 as needed;

[0065] (3) Require provider 16 to send notifications of admissions to anappropriate representative of HQM 13;

[0066] (4) Complete a telephone consultation with provider 16, conductedby an appropriate representative of HQM 13, if deemed necessary by therepresentative of HQM 13; and

[0067] (5) Assign a representative of HQM 13 to provide assistance toprovider 16 in determining appropriate services to address thehealthcare problem and to report treatments proposed by provider 16 toan appropriate representative of HQM 13.

[0068] Finally, if a “C” level NCQSP is identified at step 198 of FIG.17, then step 202 obtains a listing of intervention actions associatedwith a “C” level intervention. These actions may include the following:

[0069] (1) Obtain criteria for any admission associated with thehealthcare request, including medical history, tests, and lab work;

[0070] (2) Assign a maximum two-day length of stay or less based onconventional length of stay guidelines, and perform daily concurrentreview of additional days, requiring approval by an appropriaterepresentative of HOM 13 as needed; and

[0071] (3) Assign a representative of HQM 13 to provide assistance toprovider 16 in determining appropriate services to address thehealthcare problem and to report treatments proposed by provider 16 toan appropriate representative of HQM 13.

[0072] All of the various intervention actions listed above arerepresented by steps 204 and 206 of FIG. 17. After all of theappropriate intervention actions have been completed, the healthcarerequest is fully processed. Additional healthcare requests may bereceived at step 194 and simultaneously processed.

[0073] By applying the resources of HQM 13 to intervene with thosepatients 14 presenting the greatest risk of generating high healthcarecosts and providers 16 most likely to provide the least desirablehealthcare, the method of the present invention may result inimprovements to the healthcare consumption habits of patients 14 and tothe practice patterns of providers 16, thereby resulting in an overallimprovement of healthcare services consumed by patients 14 and costefficiency realized by employer 10.

[0074] The foregoing description of the invention is illustrative only,and is not intended to limit the scope of the invention to the preciseterms set forth. Although the invention has been described in detailwith reference to certain illustrative embodiments, variations andmodifications exist within the scope and spirit of the invention asdescribed and defined in the following claims.

What is claimed is:
 1. A method of optimizing healthcare servicesconsumption, including the steps of: assessing a healthcare situation ofan employer who provides healthcare benefits to a population thatresides and consumes healthcare services in a health economic zone;identifying a first group of patients from the population likely togenerate expensive healthcare claims relative to other patients in thepopulation based on data representing past healthcare claims generatedby the population; periodically determining whether patients in thefirst group have obtained healthcare services that satisfy predeterminedrequirements; identifying a first group of providers in the healtheconomic zone who provide high quality, cost efficient healthcareservices relative to other providers in the health economic zone basedon data representing past practice patterns of the first group ofproviders and the other providers; prompting patients who have notobtained healthcare services that satisfy the predetermined requirementsto obtain additional healthcare services to satisfy the predeterminedrequirements from providers in the first group of providers; andresponding to healthcare requests from the population by determiningwhether a patient submitting the request is seeking to obtain healthcareservices from a provider in the first group of providers, and, if not,urging the submitting patient to obtain healthcare services from aprovider in the first group of providers.
 2. The method of claim 1wherein the assessing step includes the step of comparing costsassociated with healthcare services in the health economic zone withcosts of similar healthcare services in a geographic area that is largerthan the health economic zone.
 3. The method of claim 1 wherein theassessing step includes accessing a database including informationdescribing healthcare claims of healthcare consumers in the healtheconomic zone and healthcare consumers outside the health economic zone.4. The method of claim 1 wherein the step of identifying a first groupof patients includes the step of identifying patients suffering from oneor more chronic illness.
 5. The method of claim 1 wherein the step ofidentifying a first group of patients includes the step of assigning ahealthcare index to each patient based upon factors including age andgender of the patient.
 6. The method of claim 1 wherein the periodicallydetermining step includes the step of accessing a database includinginformation describing healthcare services obtained by patients in thefirst group of patients.
 7. The method of claim 1 wherein the step ofidentifying a first group of providers includes the steps of identifyingepisodes of healthcare for each of the providers in the health economiczone and comparing characteristics of the episodes of healthcare withcharacteristics of similar episodes of healthcare associated withproviders in a geographic area that is larger than the health economiczone.
 8. The method of claim 1 wherein the step of identifying a firstgroup of providers includes the steps of calculating a cost efficiencyindex of each provider in a health economic zone, and assigning anon-certified designation to each provider having cost efficiency indexthat fails to satisfy a first predetermined condition.
 9. The method ofclaim 8 wherein the step of identifying a first group of providersincludes the steps of determining a service rate for each provider, andassigning a non-certified designation to each provider having a servicerate that fails to satisfy a second predetermined condition.
 10. Themethod of claim 9 wherein the step of determining a service rate foreach provider includes the step of evaluating the number and types ofpreventative care services ordered by each provider for the treatment ofa chronic illness.
 11. The method of claim 9 wherein the step ofidentifying a first group of providers includes the steps of evaluatingthe practice patterns of each provider, and assigning a non-certifieddesignation to each provider having practice patterns that fail tosatisfy a third predetermined condition.
 12. The method of claim 11wherein the step of identifying a first group of providers includes thesteps of assigning a qualified designation to each provider having acost efficiency index, a service rate, and practice patterns thatsatisfy the first, second, and third predetermined conditions,respectively.
 13. The method of claim 1 wherein the prompting patientsstep includes the step of contacting the patients who have not obtainedhealthcare services that satisfy the predetermined requirements.
 14. Themethod of claim 1 wherein the prompting patients step includes the stepof urging the patients who have not obtained healthcare services thatsatisfy the predetermined requirements to obtain additional healthcareservices from providers in the first group of providers.
 15. The methodof claim 1 wherein the prompting patients step includes the step ofcontacting providers who have provided healthcare services to thepatients who have not obtained healthcare services that satisfy thepredetermined requirements.
 16. The method of claim 1 wherein the stepof responding to healthcare requests includes the steps of ranking theother providers in the health economic zone based on an analysis of thequality and cost efficiency of practice patterns associated with theother providers, dividing the ranking of providers into a first level ofproviders and a second level of providers, and determining the levelinto which the provider associated with the request falls.
 17. Themethod of claim 16 wherein the step of ranking the other providersincludes the step of assigning a cost efficiency index to each of theother providers.
 18. The method of claim 16 wherein the step of rankingthe other providers includes the step of evaluating a practice patterncharacteristic of each of the other providers including one ofprocedures not appropriate for an associated diagnosis, proceduresperformed too frequently, upcoded procedures, invalid coding data, andprocedures billed with non-specific diagnosis.
 19. The method of claim16 wherein the step of responding to healthcare requests includes thestep of urging the patient to use a first level provider if theassociated provider is a second level provider.
 20. The method of claim19 wherein the step of responding to healthcare requests includes thestep of conducting a first set of intervention actions if the patientuses a first level provider, the first set of intervention actionscorresponding to a first degree of involvement of a healthcare qualitymanagement representative in the provision of services by the firstlevel provider.
 21. The method of claim 20 wherein the step ofresponding to healthcare requests includes the step of conducting asecond set of intervention actions if the patient uses a second levelprovider, the second set of intervention actions corresponding to asecond degree of involvement of the healthcare quality managementrepresentative in the provision of services by the second levelprovider, the second degree of involvement being greater than the firstdegree of involvement.
 22. The method of claim 1 wherein the steps areperformed by a healthcare quality management firm.
 23. The method ofclaim 1 wherein the data representing past healthcare claims and thedata representing past practice patterns are stored in a centralizeddatabase.
 24. The method of claim 1 further including the step ofmonitoring changes in the healthcare situation of the employer overtime.
 25. A method of optimizing healthcare services consumption ofpatients in a healthcare plan provided by an employer and administeredby a healthcare quality management firm in a health economic zone thatcorresponds to the residences of the patients and the locations ofproviders used by the patients, the method including the steps of:ranking providers in the health economic zone based on an analysis ofthe quality and cost efficiency of practice patterns associated with theproviders; dividing the ranking of providers into a first level ofproviders, a second level of providers, and a third level of providers;responding to a healthcare request from a patient by determining thelevel into which the provider associated with the request falls; urgingthe patient to use a first level provider if the associated provider isa second or a third level provider; urging the patient to use a secondlevel provider if the associated provider is a third level provider;conducting a first set of intervention actions corresponding to a firstdegree of involvement of the healthcare quality management firm in theprovision of services by the provider used by the patient if the usedprovider is a second level provider; and conducting a second set ofintervention actions corresponding to a second degree of involvement ofthe healthcare quality management firm in the provision of services bythe used provider if the used provider is a third level provider, thesecond degree of involvement being greater than the first degree ofinvolvement.
 26. The method of claim 25 further including the step ofidentifying a first group of patients likely to generate expensivehealthcare claims relative to other patients based on data representingpast healthcare claims generated by the patients.
 27. The method ofclaim 25 wherein the step of identifying a first group of patientsincludes the step of identifying patients suffering from one or morechronic illness.
 28. The method of claim 25 wherein the step ofidentifying a first group of patients includes the step of assigning ahealthcare index to each patient based upon factors including age andgender of the patient.
 29. The method of claim 26 further including thestep of periodically determining whether patients in the first group ofpatients have obtained healthcare services that satisfy predeterminedrequirements.
 30. The method of claim 29 further including the step ofprompting patients who have not obtained healthcare services thatsatisfy the predetermined requirements to obtain additional healthcareservices to satisfy the predetermined requirements.
 31. The method ofclaim 25 wherein the ranking providers step includes the steps ofidentifying episodes of healthcare for each of the providers in thehealth economic zone and comparing characteristics of the episodes ofhealthcare with characteristics of similar episodes of healthcareassociated with providers in a geographic area that is larger than thehealth economic zone.
 32. The method of claim 25 wherein the rankingproviders step includes the steps of calculating a cost efficiency indexof each provider in the health economic zone, and assigning anon-certified designation to each provider having cost efficiency indexthat fails to satisfy a first predetermined condition.
 33. The method ofclaim 32 wherein the ranking providers step includes the steps ofdetermining a service rate for each provider, and assigning anon-certified designation to each provider having a service rate thatfails to satisfy a second predetermined condition.
 34. The method ofclaim 33 wherein the ranking providers step includes the steps ofevaluating the practice patterns of each provider, and assigning anon-certified designation to each provider having practice patterns thatfail to satisfy a third predetermined condition.
 35. The method of claim34 wherein the first level of providers have a cost efficiency index, aservice rate, and practice patterns that satisfy the first, second, andthird predetermined conditions, respectively.
 36. The method of claim 25wherein the ranking providers step includes the step of evaluating apractice pattern characteristic of each of the providers including oneof procedures not appropriate for an associated diagnosis, proceduresperformed too frequently, upcoded procedures, invalid coding data, andprocedures billed with non-specific diagnosis.
 37. A method ofoptimizing healthcare services consumption by patients of a populationin a healthcare plan provided by an employer, the method including thesteps of: calculating a cost efficiency index of each healthcareprovider in a health economic zone based upon past claims information;assigning a non-certified designation to each provider having costefficiency index that fails to satisfy a first predetermined condition;determining a service rate for each provider based upon the past claimsinformation; assigning a non-certified designation to each providerhaving a service rate that fails to satisfy a second predeterminedcondition; evaluating practice patterns of each provider based upon thepast claims information; assigning a non-certified designation to eachprovider having practice patterns that fail to satisfy a thirdpredetermined condition; assigning a qualified designation to eachprovider having a cost efficiency index, a service rate, and practicepatterns that satisfy the first, second, and third predeterminedconditions, respectively; and responding to a request from an patientfor healthcare services by urging the patient to obtain the servicesfrom a provider having a qualified designation.
 38. The method of claim37 further including the step of assessing a healthcare situation of theemployer by comparing costs associated with healthcare services providedby the providers in the health economic zone to costs of similarhealthcare services provided by providers in a geographic area that islarger than the health economic zone.
 39. The method of claim 37 furtherincluding the step of comparing demographic and wellness informationrelating to the patients to demographic and wellness informationrelating to other healthcare consumers in the health economic zone. 40.The method of claim 37 further including the step of identifying a firstgroup of patients from the patient population likely to generateexpensive healthcare claims relative to other patients in the populationbased on data representing past healthcare claims generated by thepopulation.
 41. The method of claim 40 further including the step ofperiodically determining whether patients in the first group of patientshave obtained healthcare services that satisfy predeterminedrequirements.
 42. The method of claim 41 further including the step ofprompting patients who have not obtained healthcare services thatsatisfy the predetermined requirements to obtain additional healthcareservices to satisfy the predetermined requirements from providers havinga qualified designation.
 43. The method of claim 40 wherein the step ofidentifying a first group of patients includes the step of identifyingpatients suffering from one or more chronic illness.
 44. The method ofclaim 40 wherein the step of identifying a first group of patientsincludes the step of assigning a healthcare index to each patient basedupon factors including age and gender of the patient.
 45. The method ofclaim 37 further including the steps of ranking the providers having anon-certified designation, dividing the ranking of providers into afirst level of providers and a second level of providers, anddetermining the level into which the provider associated with therequest falls.
 46. The method of claim 45 wherein the responding stepfurther includes the step of urging the patient to use a first levelprovider if the associated provider is a second level provider.
 47. Themethod of claim 46 wherein the responding step further includes the stepof conducting a first set of intervention actions if the patient uses afirst level provider, the first set of intervention actionscorresponding to a first degree of involvement of a healthcare qualitymanagement firm in the provision of services by the first levelprovider.
 48. The method of claim 47 wherein the responding step furtherincludes the step of conducting a second set of intervention actions ifthe employee uses a second level provider, the second set ofintervention actions corresponding to a second degree of involvement ofthe healthcare quality management firm in the provision of services bythe second level provider, the second degree of involvement beinggreater than the first degree of involvement.
 49. A method of optimizinghealth services consumption of patients in a healthcare planadministered within a geographic area, the method including the stepsof: ranking providers located in the geographic area based on ananalysis of the quality and cost efficiency of practice pattersassociated with the providers; dividing the ranking of providers into afirst level of providers and a second level of providers; responding toa healthcare request from a patient requesting services from a secondlevel provider by accessing the ranking of providers to identifyproviders having a first level ranking located within a selectabledistance from the patient.
 50. The method of claim 49 wherein theresponding step further includes the step of urging the requestingpatient to use one of the identified first level providers.
 51. Themethod of claim 49 wherein the selectable distance is a radiusoriginating at a location of the patient.